Toward Evaluation of The Subjective Experience of A General Class of User-Controlled, Robot-Mediated Rehabilitation Technologies for Children with Neuromotor Disability

Comment: These changes were made at the recommendation of 3 peer reviewers.
Figure 2, an image of the PedBotHome footplate, was of too low resolution. We replaced it with a panel of three images, higher resolution, that show more clearly both the form of the system and how a child would interact with it. This is now labeled Figure 2a-c. In addition, we expanded the description of the device to make it easier to understand what one is seeing in the picture. We went through and applied the MDPI table and figure caption formats from the styles menu throughout. For clarity, we double-checked that all acronyms were explained. The first line of the introduction now identifies CP as the abbreviation for cerebral palsy. We also added this clarification to the abstract. A/R (assistive/rehabilitative) is now defined on first use in the introduction as well. We also added a paragraph in the introduction to clarify for the reader early on that there is a distinction to be made between “assistive” and “rehabilitative” technologies and that this distinction is ultimately essential to productive evaluation of the user experience. In addition, we re-read the manuscript with an eye to things that might not be clear to a reader outside of our rehabilitation robotics domain and inserted clarifying text.   We have reworked Table 1 (now Table 4) and it does not seem to break across pages. It is difficult to be completely sure about this, however, since the revision file provided to us by the journal is in web layout.   We expanded our description of cerebral palsy (CP) in the introduction. We also added more citations to evidence supporting our thesis that robotics and game-based therapy have demonstrated effectiveness in improving clinical outcomes in CP. We elaborated on our contention that A/R gamebots are a new class of technology. We grounded this perception in the rehab service delivery context experienced in the US where there currently is no classification under which systems such as A/R gamebots can be prescribed and reimbursed. We describe the indirection of their use that is the essence of their novelty. We now address the all-important distinction between rehabilitative and assistive technology up front since this differentiation drives the need for a tailored assessment measure for A/R gambot class technologies. We added clarification to the instrument design process we are using – a figure to supplement the logic model from the original manuscript. We also added a more in-depth description of the PedBotHome system and referred the reader to our IEEE technical paper that more fully describes the hardware and software. We added more information about the children who participated in the trial. New Table 2 provides demographics. We also discussed the limitation of small sample size in the Limitations section. By way oof comparing our work to that of others, we noted that sample sizes in the single digits or teens are unfortunately typical of our research area. The prevalence of CP is not that large, so it is always difficult to recruit a sizeable cohort of children to studies. Preliminary results are also part of an earlier manuscript we reference. We currently have a clinical paper nearing completion that will provide the final objective analysis on the impact of PedBotHome on children’s range of motion, strength and other outcomes. Our goal with this paper was to focus on the issue of subjective evaluation and acceptance. Perceived effectiveness is a part of that, predicted by both exercise adherence and exergaming theory and described in the results. We added a clarification (and supporting citations) that, even though our focus is lower extremity, robotics and gamification have been shown to be effective generally in addressing the therapy needs of children with CP, be those needs focused on lower extremity (principally gait) or upper extremity (principally dexterity). It was suggested that a game theoretic mechanism may underlie technology decision-making among parent-child dyads and likely, parent-child-clinician triads. We noted that dimension in the final paragraph of the discussion. Finally, we closely reviewed the entire manuscript, catching typos and non-sequiturs. We also worked to introduce greater clarity, shorten sentences and tighten up vocabulary.